Provider Demographics
NPI:1649820226
Name:CODILLA, MARY ANNE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANNE
Last Name:CODILLA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6681 TANZANITE ST
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91752-4461
Mailing Address - Country:US
Mailing Address - Phone:951-743-4788
Mailing Address - Fax:
Practice Address - Street 1:4301 CAROLINE CT
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2902
Practice Address - Country:US
Practice Address - Phone:951-683-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA719842163WM0705X
CA16295225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical